Psychotherapists’ views on triggering factors for psychological disorders

Triggering factors play an important role in the development of psychological disorders. Practicing psychotherapists have valuable knowledge on psychological disorders and since their views on triggering factors have not been reported in the literature, triggers were addressed in this study from psychotherapists’ perspectives. The following three main issues were examined: definitions of triggers, examples of the most recurrent triggers and the idea of a common trigger for psychological disorders. Sixteen psychotherapists agreed to participate in the study. Semi-structured interviews were conducted in person and the data collected were analyzed using frame analysis. Frame analysis aims at representing the data through frames or groups that indicate different interpretations of the same topic. The results showed that the therapists provided three definitions of triggering factors. They most often defined triggers as events, occurrences or situations that explain the onset of psychological symptoms. The psychotherapists also provided examples of triggering factors: these were grouped into three frames, interpersonal, environmental and trauma. The therapists identified no single common trigger, although they discussed common categories and connections between different triggering factors. The findings indicate that triggering factors are complex and closely connected to personal vulnerabilities, as different events and circumstances act as triggers for different individuals. Future research could expand on these findings by examining the constituents of individual vulnerabilities.


Introduction
Triggering factors were introduced as part of the diathesis-stress model or the vulnerability-stress model in the 1960s [1]. Diathesis or vulnerability referred to psychological and genetic factors that are present in individuals prone to developing a mental disorder. Stress, on the other hand, referred to environmental factors and life events that trigger or aggravate existing predispositions. This model was first utilized to explain the origins of schizophrenia, and was later modified to include psychological disorders in general. In 1980, the term trigger was presented in the third edition of the diagnostic and statistical manual (DSM), specifically in association with post-traumatic stress disorder (PTSD) and its diagnosis [2].
The treatment of psychological disorders is widely based on the origin of disorders. Psychotherapists' understanding of the causal factors for psychological disorders influences treatment approach [3]. Studies have shown that therapists separate the development of mental disorders into biological and psychological components. Disorders that are viewed to be caused biologically and neurologically form one group, while other disorders seen as caused socially and psychologically make up another [3,4]. One study showed that psychotherapists perceive mental disorders to range from highly biological to highly psychological or environmental [3]. Another study showed that therapists consider mental disorders 1 3 Prior to collecting the interview data, participants were informed that their views on the development of psychological disorders would be studied. They were also notified that the interview would be in English and that it would be recorded using a voice recorder. They were also informed that the results of this study would be published. Participants were provided with a copy of the privacy agreement containing a detailed description of the research. After verbally agreeing to these procedures and expressing their willingness to participate, they signed an informed consent form. The written consent form was also signed by the researcher conducting the interviews.
The interview was semi-structured and contained thirteen questions. Five questions were on the participants' demographics and three on their views regarding triggering factors. The data on the latter three questions were then analyzed. The interview questions are presented in Appendix 1. If needed, additional questions were asked during the interviews for clarification purposes. English was chosen as the interview language both to decrease translation bias and to utilize participants' choice of words and phrases in their perception of triggering factors.
The interviews were conducted in person and each participant was interviewed separately. The interviews took around 25 min on average and were recorded using a voice recorder and then transcribed. One interview was collected directly in writing as the participant preferred not to have their voice recorded. Apart from one interview that was mostly conducted in Arabic and subsequently translated into English, all the interview data were conducted in English. Some therapists also occasionally used Arabic to provide additional explanations and examples; these were also translated into English. Participants' personal information was protected throughout the study and their names were not included in the saved data. Participants were aware that their participation was voluntary and received a copy of the signed consent form.

Analysis
A few qualitative research methodologies were discussed in regards to the analysis of this study, such as grounded theory, content analysis and frame analysis. Frame analysis [18] was used to investigate psychotherapists' views on factors triggering psychological disorders. Grounded theory was ruled out since the aim of the study focused more on understanding therapists' perspectives and less on creating a theory on triggers [19]. As for content analysis, it was also not fitting for the scope of this study because therapist's opinions were not interpreted for the purpose of extracting underlying meaning. However, through frame analysis, participants' opinions were grouped to identify different interpretations of triggering factors.
Frame analysis was chosen because it allows examination of how certain issues are understood differently based on perception. Within frame analysis, the concept of understanding emerges from grouping social situations based on an individual frame of reference [18]. Therapists' opinions for examples could be shaped by their therapeutic approach, psychotherapy training, clinical experience and even personal knowledge [20]. Hence, utilizing frame analysis allowed the exploration of diverse outlooks therapists have regarding triggering factors.
Three interview questions were analyzed using Atlas.ti software. The data for each interview question was coded separately. The codes were created by extracting phrases and terminology used by the psychotherapists when discussing triggers. Similar explanations or codes were then grouped together to form frames. Two interviews were excluded from the analysis of the second research question as these participants' answers did not provide specific information on or examples of recurrent triggers.
The first author was responsible for conducting the interviews, for data collection, and for initial coding. The codes were then analyzed and interpreted in collaboration with the other two authors. The cooperation between authors occurred during regular meetings which included a detailed discussion regarding coding, agreement on the most representative titles for frames and appropriate placement of the codes within each frame. The first author holds a master's degree in clinical psychology with supervised psychotherapy training in several therapeutic approaches with no specific focus. The other authors had received psychotherapeutic training in systemic therapy, utilize an integrative approach in their clinical practice and have substantial experience in qualitative research.

Definitions of triggering factors
The first research question focused on the definition of triggers or triggering factors. The psychotherapists were asked to define what they considered constituted a triggering factor. Analysis of the data yielded three definitions or frames that were labeled situational, past experiences, and non-specific. Table 2 presents the three frames and the number of times each definition was mentioned by the psychotherapists. The most frequently mentioned was the situational frame.

Situational frame
The triggers that were mentioned in this frame included, in the words used by the interviewee, events, incidents, changes, new situations, circumstances, happenings in the environment, and something individuals are exposed to. The occurrence of events could be either in the past or the present. Past changes or events occurring at the time of emergence of psychological symptoms were for instance divorce experienced in childhood, whereas present events were for instance relocating to a new country.
The effects of triggers as described by the therapists were activation of psychological symptoms leading to distress on an emotional, psychological or physical level, resulting in dysfunction or feelings of loss of sense of control as well as stimulating a system of thinking and behaving. Moreover, the therapists explained that the effects of a triggering factor are dependent on the individual's vulnerabilities and capacity for resilience.

Past experiences frame
The psychotherapists identified another definition for triggering factors as elements of the present environment that resembled negative events experienced by the individual in the past. Some therapists used expressions such as the present environment or present happenings. Past experiences were described by phrases such as negative past experiences, unfulfilled emotional needs from childhood, and past trauma. Some therapists stated that triggers could be minor events that nevertheless generate a huge reaction in individuals. This reaction, linked to past experiences, is thus not usually The association between triggers and the brain or the central nervous system was also discussed. The effects of triggering factors were described as arousing the central nervous system, leading to a psychological, emotional or behavioral reaction as well as raising tension and possibly leading to psychological symptoms.
• Interview 11: An element in your environment, in the present, that is somehow similar either in setting, in content, or in the personality of the individuals around you to a previous actual trauma that you have gone through. • Interview 14: A triggering factor is anything that might happen in the present that stimulates something in the person's mind or feelings or even behavior. For example, when something happens in the present and it just reminds the person of a negative experience in the past, the brain links that together and the experience in the past with all its cognitions and feelings are relived in the present…the person might feel very upset and this wouldn't usually be proportional to what is happening in the present.

Non-specific frame
The triggers in this frame remained undefined or vague. The therapists provided a general definition of a trigger and focused on its effects rather than labeling it or specifying the elements a triggering factor. Therapists used words such as a factor, anything or something in their definitions. They described a trigger as something normal that has a strong effect on particular individuals. Such effects included inducing a psychological disorder, activating symptoms, and causing dysfunction or loss of control.
• Interview 1: Factors that activate symptoms, contribute to its beginning, or activates the disorder in some way.
• Interview 9: Something that makes the person go out of control, when others around might see it as something very normal, but it makes the person completely dysfunctional.

Most recurrent triggering factors
The second research question aimed at eliciting the most recurrent triggering factors. The psychotherapists were asked to describe and exemplify the triggers they had encountered most often in their clinical practice. All mentions of these triggers were extracted from the data and grouped into three frames: interpersonal, environmental, and trauma. Table 3 presents the three frames and their frequency of occurrence in the data. The interpersonal frame contained the most mentioned triggers.

Interpersonal frame
The most recurrent interpersonal triggering factors mentioned by the interviewees included relationship issues such as break-ups, being in a difficult relationship, losing trust in a relationship, and the death of a loved one. The therapists also mentioned unsupportive family or societal support systems as well as dysfunctional support systems. Personality differences, whether between parents and children or between couples, that create problematic interactions were also mentioned. This frame also included family issues and unmet childhood needs, such as children not feeling understood by their families or not receiving enough attention, care and emotional support from their parents. Unmet childhood needs were discussed in relation to negative cognitions and individuals' perceptions of themselves and the world.

Environmental frame
The main examples in this frame were challenging situations, stressful life events, or changes that an individual is subjected to. Examples of environmental triggers given by the therapists included financial difficulties, unemployment, poverty, accidents, being the victim of a crime such as robbery, changes in an individual's environment such as relocating to a new country, changing schools or jobs, and developmental or health-related changes like an illness. The absence of certain coping skills or having poor coping skills in certain areas of life were offered as possible reasons why certain events are challenging and become triggers for some people and not others. This frame represents factors that are not based on human interaction, which is noticeably distinct from the interpersonal frame. Many environmental triggers were included except for trauma related triggers which constituted the third frame in this study.
• Interview 2: Changing of the environment, like relocating to different places, difficulty integrating usually is a big problem, like changing schools, changing jobs, changing countries. • Interview 14: Typically, the most recurrent triggers would be a challenging situation for this specific person who perhaps has poor coping skills in that specific area. • Interview 15: Poverty in this situation, specifically within the population that I work with. Their constant inability to make ends meet, not having a job, trying to find a job; it triggers a lot of things such as anxiety and depression.

Trauma frame
Triggering factors related to trauma or abuse were considered by the therapists in this frame to be the most recurrent triggers they had encountered in their clinics. They cited such factors as emotional, verbal, or sexual abuse, neglect, traumatic events such as war or torture, and childhood traumas resulting from bullying or witnessing intense conflicts between parents. The therapists also stated that anything that reminds the individual of a previously experienced trauma could act as a trigger. Such reminders included hearing a certain tone of voice, watching a movie, being in a new job in a new setting or the personality of a boss or close individual. •

Common trigger
To answer the third research question, the psychotherapists were asked whether or not they thought there was a common triggering factor for most psychological disorders. They gave different answers and showed different ways of understanding the question. Similar answers were grouped together, yielding three frames: connectivity, categorization and dismissive. Within all three frames therapists seemed to disagree with the idea of a single common trigger. Table 4 presents the three frames and their frequencies. The connectivity frame was the most frequent.

Connectivity frame
In this frame, the psychotherapists focused on the common features of triggers and gave explanations of what, in their opinion, connects triggers together. Their understanding of the question regarding the presence of a common trigger focused on commonality, such as a common cause for triggers or a common reaction that triggers provoke in individuals. Even though some therapists clearly stated that they do not think there is one common trigger, they still provided common aspects for triggers. Two subcategories were mentioned explaining the connections between triggers: common outcome and common cause. Therapists mentioned the following common outcomes of triggers: distress, feelings of vulnerability, helplessness and confusion, losing control and losing one's identity. Another connector they mentioned was a common cause or a common origin for most triggering factors which is past unresolved trauma.
• Interview 3: What is common with triggers is confusion and a sense of not knowing what to do and not having control…it is when people want to change a specific situation but they can't so that gets confusing and they start having problems. • Interview 6: There is a common cause for triggers which is trauma, but no common trigger.

• Interview 7: I think every individual is different, so every trigger is different, but the common denominator would be that it causes distress. Whatever the situation is and whatever the trigger may be, it all leads to the person feeling distress. • Interview 12: Definitely there has to be something in common, it is the point where something happens to you and you get lost. What triggers have in common is a situation which makes me vulnerable, regardless of the type of trigger, a situation that puts me in a certain state of mind where I feel maybe helpless, I feel that I am not in control anymore. That is the trigger, something that pushed me and I cannot.
It is the reaction that people have in common, disregarding the differences, it is the fact that I had enough.

Categorization frame
In this frame, common themes or common categories were mentioned in response to the question of whether psychological disorders have a common trigger. Psychotherapists explained that while there is no single specific common triggering factor, triggers have common elements that they have observed in their clinics. Thus, although the views in this frame discounted the idea of one common trigger, they nevertheless emphasized that triggers shared common themes, such as the family, the environment, traumatic events, and unmet needs. Other common categories were interpersonal issues, recurrent negative experiences, abuse, as well as issues related to power, safety or security, love and acceptance, self-competence or self-worth, and responsibility.

• Interview 2: I do believe that what is common in most triggers of psychological disorders is unmet needs but I cannot discount biology, so for that reason I couldn't say there is a common trigger.
For me the answer would be no, but I would say that a well-adjusted family is certainly a protective factor. • Interview 4: Not a common trigger, but there are common themes. So it is not one common trigger but there are common themes which are related to self-competence, love and acceptance, safety and danger. • Interview 14: It is interpersonal issues and interpersonal problems. You could also be dealing with something else, for example you may have problems with achievement or with self-esteem but then again self-esteem is basically how you were looked at when you were a child, whether you were praised or criticized. It goes back to interpersonal issues. • Interview 16: Traumatic events, but not for all, not in general. I believe there isn't one common triggering factor, several factors play a role. One of the major ones is traumatic events amongst others.

Dismissive frame
Therapists in this frame dismissed the idea of a common triggering factor. They did not provide further explanation other than it would be too reductionist to suggest a single common trigger for psychological disorders.

Discussion
The aim of this study was to identify the viewpoints of psychotherapists on triggering factors. Three main issues were addressed: the definition of a trigger, examples of the most recurrent triggers, and the existence of a common trigger. First, different definitions for a triggering factor were grouped into three frames: situational, past experiences and nonspecific. In the situational frame, which was the most frequently mentioned, triggering factors were seen as circumstances or events that individuals are exposed to. In another definition, triggers were seen as elements in the present environment that resemble past negative experiences. Second, the psychotherapists' views on the most recurrent triggering factors were grouped into three frames: interpersonal, environmental and trauma. The interpersonal frame was the most frequently mentioned and included triggers relating to relationships with others, family issues, personality differences and dysfunctional support systems. Examples of triggers relating to environmental circumstances or trauma constituted the other two frames. The third research question focused on whether or not psychotherapists considered that mental disorders were triggered by a common factor. The answers seemed to differ, according to the way the question was understood, and were grouped into three frames: connectivity, categorization and dismissive. The connectivity frame included two subgroups for connections the therapists considered to be common for most triggers, which were common outcome and common cause. What constitutes a triggering factor has not been precisely defined in previous studies. The terms trigger and risk factor seemed to be used interchangeably. According to previous research, while risk factors do not necessarily induce symptoms, and certain risk factors such as genetics need a trigger in order for a disorder to develop, the accumulation of risk factors could lead to the development of symptoms [9]. In this study, the definitions the psychotherapists offered for triggering factors yielded a different classification from that of risk factors. First, the psychotherapists argued that the triggers occurred immediately prior to the onset of symptoms. Moreover, the majority of the therapists seemed to agree on the effects of triggering factors, which included distress, dysfunction, and psychological symptoms, resulting in an emotional, psychological, or physical reaction, and loss of sense of control. Some therapists in this study also discussed the accumulation of negative events or the buildup of unprocessed traumas which could become a trigger. They explained that a triggering factor is not necessarily a huge event; it may sometimes be the addition of a minor event that pushes the individual over the edge.
Although the therapists in this study defined triggering factors in a way that distinguishes them from risk factors, the examples they gave showed some similarities. The examples of triggers and risk factors given in the literature include environmental factors, stressful life events, social stress, social withdrawal, trauma. abuse, family issues, low socioeconomic status, genetic vulnerabilities, neurotransmitter imbalance, feelings of hopelessness, negative affect, personality traits, sleep problems, and loss of a partner [6][7][8][9][10][11][12]. The psychotherapists in this study also mentioned family issues, poverty, environmental changes, stressful life events, death of a loved one, trauma, abuse, feelings of helplessness and personality differences as triggering factors. However, they did not mention genetic vulnerabilities or neurotransmitter imbalance as triggering factors. The triggers they focused on all fell within the interpersonal, environmental and trauma frames, while they made no mention of neuropsychological or medical factors, which would mainly be classified as risk factors.
Earlier research showed that social stress can trigger paranoia in individuals at risk for psychotic disorders, explaining that it is the individual's reaction to a stressor that determines the prevalence of the symptoms and not the type or intensity of the stressor [8]. The psychotherapists in this study complemented this perspective by arguing that triggers could be normal events that, however, affect specific individuals differently, precisely because of their individual vulnerabilities. For some therapists these included weak coping skills in certain areas of life such as work, personal relationships, or family. Others focused on past negative experiences and their role in shaping an individual's cognitions, perceptions and emotional reactions. Some also mentioned past unresolved trauma as the origin of most triggers.
A recent study of feelings of hopelessness in an adult migrant population found that hopelessness acted as a mediator between childhood traumatic events and depressive symptoms [7]. The hopelessness theory similarly explains how hopelessness can affect the development of depressive symptoms [6]. In this study, the psychotherapists stated that most triggers have connections with feelings such as distress, vulnerability, helplessness and confusion, loss of sense of control, and loss of identity. Moreover, most triggers were also connected with past unresolved trauma. Although the psychotherapists did not use the word hopelessness, their opinions were clearly informed by a similar notion.
In this study, therapists defined triggering factors as events, situations or occurrences which are linked to past experiences and that activate intense reactions, psychological symptoms or even disorders. This definition combines aspects from the three frames provided by the therapists. In addition, some therapists discussed triggers in relation to psychotherapy and stated that the client's explanation of their problem is generally different from the reason they are suffering or having difficulties. During their first session, clients are asked why they have come to therapy and they answer providing an explanation of the issues they are facing. However, the factors triggering their problems are not always clear to either the client or the therapist. Throughout therapy, triggers reveal themselves. This process is dependent on the client's willingness to discuss their life surrounding the onset of their symptoms, including events that they might experience as uncomfortable and challenging. During therapy sessions, something said or done by the therapist may also trigger reactions in clients. Such occurrences are also important elements of therapy, as they create an opportunity for both the therapist and the client to discuss the situation, understand what it was that had bothered the client, learn about the client's triggers, and treating past experiences linked to the trigger. An important part of resolving triggers is achieved through emotionally processing past experiences in a healthy way; which renders past traumatic experiences into just memories [21].
With respect to recurrent triggers, those that were most often mentioned were found in the interpersonal frame. Abuse and neglect were viewed by some therapists as traumas per se, while others categorized neglect as part of unmet childhood needs, which is also a trigger in the interpersonal frame. Other triggers related to past traumas, such as the personality of others or being criticized by someone, might also be considered as interpersonal. Some therapists explained that some issues, such as experiencing performance anxiety at work, are connected to self-esteem which, in turn, is generally based on how much an individual was criticized or praised when growing up. Even an environmental factor such as moving to another country, could also be considered as interpersonal trigger, especially if it is associated with difficulties in adjusting or relating to a new social setting. These findings indicate that several triggers might originate in relationships with others, thus testifying to the importance of past and present interpersonal interactions.
The environmental and trauma frames were also seen as important. For example, war and poverty were discussed as examples of triggers in both the environmental and trauma frames. This overlapping between frames demonstrates the difficulty of categorizing life events and individual experiences, which act as triggers for different reasons across individuals, and further indicates the link between triggers and individual vulnerability.
The psychotherapists seemed to understand the third research question differently. They were asked whether or not they thought psychological disorders share a common trigger. Some stated that triggers have common outcomes or causes, others that common categories of triggers exist, such as the family, the environment or trauma, and many mentioned that there is no single common trigger. The uncertainty in the therapists' answers demonstrates their striving to maintain an integrative approach as well as their unwillingness to limit attributing the onset of psychological disorders to a single common trigger.
The therapists suggested common themes and connections between triggers which also indicated their complexity. Common categories included interpersonal issues, unmet needs, recurrent negative experiences, abuse, and issues related to power, safety or security, love and acceptance, self-competence or self-worth, and responsibility. Others stated that triggers fall under the main headings of family, trauma, and the environment. On the issue of common outcomes of triggers, the therapists stated that triggers lead to distress, feelings of vulnerability, helplessness and confusion, loss of control and loss of one's identity. Another common feature underlying triggers was past unresolved trauma. These findings show that while triggers have common effects on individuals and could belong to similar categories, each case needs to be assessed individually.
The COVID-19 pandemic could be considered an environmental trigger since it originated from situational events. It is likely that the pandemic will have a lingering and prolonged influence on the occurrence of psychological symptoms and disorders. Several of the shared outcomes of triggers, such as feelings of distress, vulnerability, helplessness, confusion, loss of control, and loss of one's identity, discussed in this study were present during the pandemic. The unpredictability and apparent uncontrollability of the pandemic might have also induced a sense of hopelessness. The restoration of psychological health occurs, as a combined effort between therapists and their clients, in creating an opportunity for clients to reconnect with their sense of control and mastery. Whether through learning new coping skills or better understanding and perceiving their own power, individuals need to be able to visualize their choices instead of being on the receiving end and simply reacting to what is happening. This, in turn, facilitates people's capacity to adjust and cope, even in the face of unpredictable and uncontrollable triggers.

Strengths and limitations
Previous research concerning psychotherapists' viewpoints on triggering factors is limited. This study provided novel and abundant information on this topic. The participating psychotherapists communicated their thoughts and perspectives on triggering factors, offering definitions of triggers along with examples and themes. Connections between triggers were also discussed in addition to the relation between triggering factors and individual vulnerability.
This study also created an opportunity to understand triggering factors from a comprehensive point of view, especially that the participation of psychotherapists was voluntary, and analysis of the data was done irrespective of the participants' therapeutic approaches.
This study has its limitations. First, the frames in which the different examples of triggers were collected seemed to overlap. The most recurrent triggers were distributed in three framesinterpersonal, environmental and traumaalthough some could similarly be in more than one frame. Second, two interviews were omitted from the data, as they lacked concrete examples.
Although English is not the native language of the participants in this study, the use of English in the interviews is not considered a limitation. Most of the participants had either studied or worked in English and some had received training and also taught in English at university level. Only one interview was translated from Arabic into English, and translations were otherwise minimal. However, the differences in the therapists' understanding of the third research question may be linked to their English language skills. Although, it is also possible that therapists' answers differed not because they had misunderstood but because their perspectives and their way of interpreting the question were different. Moreover, their different responses yielded valuable knowledge on triggering factors and enriched the findings of this study.

Conclusion
This study examined the viewpoints of psychotherapists on triggering factors. The data yielded information on the definitions of a triggering factor, the most recurrent triggers, and therapists' views on the existence of a common trigger. The results showed that triggering factors were considered as events, situations or occurrences that are linked to past experiences and that explain the onset of individuals' problems or symptoms. Triggering factors are often everyday events that are triggers for some people but not others, as triggers are closely connected to personal vulnerabilities such as poor coping skills, negative experiences, or past trauma. Finally, while the therapists identified no single common trigger, they discussed common categories and links between triggering factors.
Future research could expand on the findings of this study and examine the factors underlying triggers. Understanding the constituents of individual vulnerability would provide valuable information. Recognizing the reasons why certain kinds of events are triggering could aid in both prevention and treatment. Moreover, with respect to the feelings of helplessness, vulnerability and loss of control that triggers evoke, it would be interesting to examine the ways in which therapists could help their clients regain their sense of control and mastery.
Author contributions The collection of the data and analysis were done by the corresponding author. All authors made a substantial contribution to the concept of the article, the interpretation of data, and the revision of article drafts. All authors have read and approved the submitted manuscript and agreed to be accountable.
Funding No funding was received for conducting this study.

Data availability
The datasets analyzed during the current study are not publicly available due to the absence of consent from participants for absolute distribution of the data.
Code availability Not applicable.

Declarations
Ethics approval and consent to participate All procedures performed in this study were in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Finnish National Board on Research Integrity indicated that an ethical approval is not required for this study. Informed consent was obtained from all individual participants included in the study.

Consent to publication
The participants have consented to the use of their interview data for publishing.

Competing interests
The authors declare that they have no competing interests that are relevant to this article.
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